A workshop report on HIV mHealth synergy and strategy meeting to review emerging evidence-based mHealth interventions and develop a framework for scale-up of these interventions.

mHealth is a term used to refer to mobile technologies such as personal digital assistants and mobile phones for healthcare. mHealth initiatives to support care and treatment of patients are emerging globally and this workshop brought together researchers, policy makers, information, communication and technology programmers, academics and civil society representatives for one and a half days synergy meeting in Kenya to review regional evidence based mHealth research for HIV care and treatment, review mHealth technologies for adherence and retention interventions in anti-retroviral therapy (ART) programs and develop a framework for scale up of evidence based mHealth interventions. The workshop was held in May 2011 in Nairobi, Kenya and was funded by the Canadian Global Health Research Initiatives (GHRI) and the US Centre for Disease Control and Prevention (CDC). At the end of the workshop participants came up with a framework to guide mHealth initiatives in the region and a plan to work together in scaling up evidence based mHealth interventions. The participants acknowledged the importance of the meeting in setting the pace for strengthening and coordinating mHealth initiatives and unanimously agreed to hold a follow up meeting after three months.


Introduction
There have been calls for more evidence on the effectiveness of mHealth interventions to improve health outcomes. The WelTel Kenya1 intervention evaluating the use of mobile phones to improve adherence to ART is the first randomized controlled trial to show the effectiveness of using mobile phones for viral suppression [1]. With these findings in place and with the ever-increasing mHealth interventions being developed, a coordinated approach among various players is essential to maximize the potential of mHealth in health system strengthening. This was the rationale for a meeting of mHealth stakeholders that reviewed the work that is going on in the region and aimed at forging a united front for scaling up evidence-based mHealth interventions. The two-day workshop in May 2011 was held in Nairobi, Kenya and was jointly organized by the University of British Columbia (UBC) and the University of Nairobi Institute of Tropical and Infectious Diseases (UNITID), and funded by Global Health Research Initiative (GHRI) and Centre for Disease Control and Prevention (CDC) Kenya.
High level adherence of 95% and above that can yield maximum viral suppression and reduce drug resistance to antiretroviral medications is still a challenge. Earlier studies with meta-analyses on adherence to anti-retroviral therapy (ART) in sub-Saharan Africa found that a pooled estimate of 77% of patients in African settings achieved adequate adherence (95% of prescribed pills), compared with 55% of patients in North American settings [2]. However, adherence still poses a challenge in resource limited settings and there is still evidence of high rates of patient lost-to-follow up [3].
Interventions using mobile phones to improve health outcomes such as adherence and retention in the ART programs are likely to be viable due to the wide access to mobile phones in most developing nations [4], the emerging evidence to support use of mobile phone interventions to improve health service delivery and the likelihood of these interventions leading to cost saving measures in the health system.

Aim of the workshop
The aim of the workshop was to bring together various stakeholders who included researchers, academicians, information, communication and technology programmers, policy makers and members from the civil society to:1) review evidence based mHealth research for HIV care and treatment; 2) review mHealth applications developed to support adherence and retention in ART programs; 3) develop an mHealth evidence based framework for scale up and 4) identify gaps in evidence and the areas where more research is needed.
On the first day of the workshop the mHealth concept, ART adherence and retention challenges and the role of mHealth, evidence for HIV-related mHealth interventions and mHealth interventions in other areas were presented and discussed. The second day of the workshop was dedicated to building partnerships and developing a framework for mHealth strengthening to support HIV care and treatment and other health conditions.

Participants
Fifty participants from twenty nine organizations in Kenya, Uganda, Zambia, Cameroon and Canada attended the workshop. They included researchers, policy makers, health care implementers, information, communication and technology programmers, academicians and civil society representatives. Although the workshop initially targeted thirty participants, the high demand necessitated a request for additional funding to accommodate more participants.

Day 1: mHealth Projects and lessons learned
There were seventeen brief presentations during the first day, in which thirteen mHealth projects either in progress or completed, were discussed ( Table 1 and Table 2). Some of the key issues and lessons learned from these presentations included: 1) Adherence to antiretroviral medications continues to be a serious problem. Lester et al., 2010 mobile phone adherence intervention conducted in Kenya report that only 66% of patients on ART in the control arm with viral loads available achieved viral suppression (<400 copies/ml) after one year [1]. A study by Eleches et al., 2011 reported that only 40% of the patients achieved adherence levels above 90% over one year [5]. A study in Cameroon reported that 77% of patients on ART had poor adherence to clinical appointments [6]; 2) Evidence on interventions that use of mobile phones to support patients taking antiretroviral medications is emerging and these interventions can be used together with other proven interventions such as targeted adherence counseling to improve adherence; 3) Evidence suggests that weekly text message reminders are more effective in improving adherence compared to daily text messages [1,5]. A survey of patients attending a clinic in Nairobi, Kenya suggested patients are more interested in using cell phones to access health care providers than for medication reminders. Mobile phone initiatives may therefore be most effective when they are designed to link patients to health care providers through improved patient-provider communication that provides regular support to patients. This was also demonstrated by the WelTel Kenya1 trial; 4) Evidence based mHealth interventions to improve health outcomes need to be scaled up to ensure that the impact is felt by a large number of people in order to enable equitable access to health service provision throughout the country; 5) Proven HIV mHealth interventions may be immediately applicable to the management of other diseases requiring long term medication such as tuberculosis, diabetes, asthma and cardiovascular diseases; 6) Development of mHealth applications should be guided by health system needs and not simply driven by the technology; hence the importance of involving all the stakeholders such as health care providers, patients, government and other stakeholders in needs assessment before developing the applications; 7) Engagement of patients is critical in developing mHealth interventions to ensure their values and perceptions are incorporated to achieve the right content (message) and intensity (message dose) of the text messages. Specific considerations that would need to be taken into account for reviews of the existing and upcoming evidence ( Table 3) based on ongoing and completed studies [5,7,8] were also identified; 8) There is a potential for mHealth to improve health management information system (HMIS) related to HIV/AIDS and other health interventions in relation to data accuracy, completeness and timely reporting, leading to improvements in ARV stock management in health centres, better access to pharmaceuticals among HIV/AIDS patients, and ultimately higher rates of ARV adherence due to reduced health system failures.

Day 2: Way forward/ recommendations
The second day of the workshop was dedicated to developing a strategic action plan for strengthening of mHealth interventions to support care and treatment of HIV and other conditions. The participants formed three discussion groups that formulated the following recommendations: 1) To develop and submit a harmonized regional evidence-based ART adherence and retention mHealth intervention. A regional stepped wedge study design [9,10] based on the evidence of the WelTel Kenya1 randomized controlled trial was proposed for regional implementation; 2) To work towards developing policy guidelines on mHealth implementation as well as ensure the existence of a legal framework to guide scale-up of mHealth interventions and uphold confidentiality and privacy of patient data. Participants suggested they would like to be involved in developing mHealth guidelines and since there is an existing e-Health committee in Kenya, one of the participants should be assigned to represent the mHealth pillar in this committee; 3) To work towards interoperability of mHealth systems to facilitate and foster collaboration in development of viable applications that are scalable, open source and can measure health outcomes; 4) To develop and communicate best practices in strategies and approaches for private-public partnerships in mHealth. Participants were interested in understanding how others have created strategic private-public partnerships and how these approaches can be used in mHealth; 5) To organize a follow up mHealth strategy meeting in three months time to concretize the recommendations developed during this meeting. The subsequent meetings should ensure adequate engagement of the government, donor agencies such as WHO, CDC UNAIDS, USAID, and IDRC and pharmaceutical companies.

Conclusion
The workshop generated greater interest for participation than expected which indicated the desire for a coordinated approach to implementing mHealth interventions in the region. It created a forum for participants to share and review mHealth interventions in the region. The evidence reviewed suggests that mobile phones can be used as monitoring and supporting tools to provide regular communication between patients and health care providers. A regional evidence-based cell phone intervention to support patient adherence and retention in ART programs was proposed. Participants acknowledged the importance of the workshop and agreed to hold a follow up meeting to reinforce the recommendations developed during this workshop.   and building capacity to conduct HIV prevention trials. IDRC, through GHRI, is funding the trial on harnessing mobile phones for prevention of mother to child transmission in Kenya.